Contemporary Boat Coverage Quote Request

If you'd like a proposal for Contemporary Coverage, please complete this form and press the "Submit" button at the end for a no-obligation quote. If you prefer, you can call our office toll free at 1-800-959-3047. You can even download our application form, print it out and fax it to us at 1-860-572-5919 or send it by mail. We'll be happy to help you.

About Your Boat

Vessel Name:      Model:     Length:        Year:  
Builder:                         Designer:
Boat Type: If Other: Motor Type:  If Other             
Hull: If other:    
Number of Engines:  Horsepower of Each:   
Max Speed:   Fuel: Gas Diesel Other
 Purchase Date:   Purchase Price:
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About Your Boating

Mooring location: City: State:   ZIP:   Security Provided: Yes No
Lay up location: City: State:   ZIP:   Security Provided: Yes No
Present location:    City:   State:    ZIP:
Waters navigated:         
Annual lay up:   From:    To:    Wet Lay Up?    If none, check here
Use of boat:
Private pleasure use only   Live aboard (primary residence)   Chartered (Six pack only, max. 20 per year)
      Your years of boating experience:                  Your years of boat ownership:
      Previous boats owned: (type, length, number of years owned)
Power Squadron or USCG Auxiliary Course? Yes No
Do you have a Captains License? Yes No    Level
Member ACBS or other owner's club? Yes No      Name of Owner's Club
Do you have a Paid Captain? Yes No              
Do you employ Paid Crew Yes No   If yes, Number 
Has your Marina asked to be listed as additional insured?  Yes No 
Is there a loan on your boat?  Yes No 

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About Your Coverage

Current or previous insurer :
Policy expiration:   

Limits of Insurance Requested

Hull & Machinery $                     Marine Liability $

Dingy Value $  Dingy Mfg    Trailer Value $    Trailer Mfg  
Medical Payments $10,000 / Personal Effects $2,500 or other.... $
Deductible:
Claims (Please list dates and amounts):   No Claims 
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About You

Name:     Date of Birth:   Email Address:
Address, City, State, Zip:
Please list the names and ages of any other regular operators:
Name:  Age:       Name: Age:
Have you ever had boat insurance canceled or non-renewed?      No   Yes
If yes, please explain.
Daytime Phone:          Evening Phone:
Fax Number:         Cell Phone:       
Other comments: (Please add as much detail as you wish)

How Did You Hear About Us?: